GERD and Asthma

• GERD (silent or symptomatic, proximal or distal) is associated with asthma, but the pathophysiologic mechanism is unknown and it is not known whether GERD treatment improves asthma.
• PPI side effects include reduced absorption of calcium and iron, impaired vitamin B12 absorption, gastric hyperplasia, increased occurrence of pneumonia and TB, interference with clopidogrel (pantoprazole less effect)

Recommendations (Ledford)

• Treat all patients with asthma and GERD who have significant symptoms of indigestion or clinical GERD for 4‐12 weeks with acid suppression and evaluate asthma clinical response. If improvement of asthma, taper acid suppression but if symptoms reoccur within weeks of treatment discontinuation would refer to GI consultant to exclude Barrett’s esophagus or would refer all patients with family history of esophageal cancer.
• Consider a barium swallow or refer all patients with symptoms of mild dysphagia associated with asthma
• Treat for 4‐12 weeks with PPI all patients with asthma and throat clearing cough, hoarseness or post laryngeal erythema on nasopharyngoscopy
• Consider treating with PPI children with persistent cough and asthma but also would consider referring to GI specialist
• Would generally not treat longer than 6 weeks without seeking a GI opinion
• Do not suggest treating adults with poorly controlled asthma and without symptoms to suggest GERD, particularly would not recommend prolonged treatment trial in light of potential side effects of PPI therapy

Laryngo/nasopharyngeal Reflux (LPR/NPR)

• Supraesophageal reflux disease (SERD) has been proposed as a name for LPR with respiratory complications (rhinosinusitis, asthma)

Clinical Features

• Chronic cough
• Throat clearing
• Hoarseness, chronic/intermittent laryngitis, dysphonia
• Globus or post-nasal drip sensation
• Sore throat
• Otalgia, eustachian tube dysfunction
• Dysphagia
• Apnea, laryngospasm
• Other manifestations may include erosions of teeth, idiopathic pulmonary fibrosis or chemical aspiration pneumonitis, bronchiectasis

Diagnosis

• RSI >13 considered abnormal and suggestive of LPR
• Barium swallow, laryngeal examination, endoscopy, and ambulatory 24 hour esophageal pH probe, BRAVO capsule have limited sensitivity/usefulness
• Nasopharyngeal pH monitoring (Restech Dx pH) may confirm LPR but not widely available
• Therapeutic trial with double dose PPI (H2 blockers generally ineffective for SERD but bedtime use can be tried), one month usually sufficient to see an improvement, but this may still fail if the problem is non-acid reflux

Management Algorithm

Behavioral Modifications

• Tobacco cessation
• Avoid large meals
• Avoid exercise after eating
• Avoid lying supine within 3 h of eating/drinking
• Elevate head of bed 6"
• Sleep in left lateral decubitus position
• Avoid caffeine, alcohol, acidic foods, and other reflux-promoting foods

Anti-reflux Treatment

Medications

Note

• PPIs
  • No significant difference in efficacy between PPIs; switching PPIs (especially more than once) is questionable
  • Take PPIs 30-60 min before meal (usually before first meal of the day), with the following exceptions:
    • Omeprazole/bicarbonate (Zegerid) is immediate release and more effectively controls nocturnal gastric pH in the first 4 h of sleep compared with other PPIs when each is given at bedtime
    • Dexlansoprazole (Dexilant, dual delayed release) can be taken any time of day regardless of food intake
  • PPIs are either enteric coated or combined with sodium bicarbonate (Zegerid) because their bioavailability is decreased when taken with a meal and exposed to stomach acid
  • If once daily dosing ineffective, adjustment of dose timing and/or twice daily dosing should be considered
• H2-RAs
  • Used as a maintenance option in patients without erosive disease if patients experience heartburn relief
  • Bedtime H2RA therapy can be added to daytime PPI therapy in patients with objective evidence of night-time reflux, but this may be associated with tachyphlaxis after several weeks of usage

Lifestyle Modifications

• Head of bed elevation
  • Place 6-8" blocks under the legs at the head of the bed or a styrofoam wedge under the mattress
  • Most important for patients with nocturnal or laryngeal symptoms
  • Pillows are not a substitute
• Dietary changes
  • Avoid reflux-inducing foods (fatty foods, chocolate, peppermint, carbonated drinks, acidic drinks, alcohol, caffeine) and other foods known to cause symptoms
  • Do not lay down after meals and avoid meals within 3 hours of bedtime
  • Avoid tight fitting clothes around abdomen
• Weight loss
• Promote salivation by chewing gum or using oral lozenges (salivation neutralizes refluxed acid and increases the rate of esophageal acid clearance)
• Sleeping in the left lateral decubitus position

References